›› Medical Control

Medical risk management actor, the medical control:

• Advises social security beneficiaries and healthcare professionals on medico-social regulations;
  ● Supports insured individuals and collaborates with healthcare professionals to improve the care of social security beneficiaries, especially those with chronic illnesses;
  ● Analyzes and monitors benefit claims;
  ● Ensures the application of existing laws and regulations.

Structure and Organization

Composed of advisory practitioners (medical advisor, dental advisor) and administrative staff, medical control is organized nationally and locally in a hierarchical structure.

The control mission carried out by the medical advisor ensures the application of social security legislation and regulations and allows every insured individual to benefit from the services appropriate to their health condition.

Missions

The medical advisor receives the medical files of insured individuals, submitted by the benefits service for review by the medical control. The advisor may summon the patient if they believe their presence is necessary. After reviewing the medical file, the advisor issues an opinion on the social benefit reimbursement request and replies to the benefits department. The opinion may concern a medication prescription, sick leave, a request for chronic illness coverage, disability, work accidents, occupational diseases…

Medical control may be carried out:

• before benefit payment (pre-control) or after payment (post-control);
• A favorable opinion is issued when the advisor has sufficient and justifying evidence for the benefit request;
• Medical information is collected from the medical file and/or from the treating physician;
• A medical rejection is issued in case of disagreement between the treating doctor and the advisor regarding the patient’s health condition;
• The appeal route is medical expertise;
•  The insured person submits the expertise request;
• An administrative rejection is issued when there is disagreement on the application of regulations;
• The appeal route for administrative rejection is the Local Qualified Preliminary Appeals Commission (CLRPQ) as the first instance, and the National Qualified Preliminary Appeals Commission (CNRPQ) as the second instance;
• Disputes concerning the assessment of disability status and incapacity rates in work accidents or occupational diseases are handled by the Qualified Wilaya Disability Commission (CIWQ);